Citation Nr: 1234918 Decision Date: 10/09/12 Archive Date: 10/17/12 DOCKET NO. 07-18 577 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUE Entitlement to service connection for a low back disorder. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Donna D. Ebaugh, Associate Counsel INTRODUCTION The Veteran served on active duty from November 1953 to January 1954. This matter is on appeal from a November 2006 rating decision by the Montgomery, Alabama, Department of Veterans Affairs (VA) Regional Office (RO) that determined that the Veteran had failed to submit new and material evidence to reopen a claim for service connection for low back disability. In November 2010, the Board found new and material evidence did exist and reopened the claim. The claim was then Remanded for further development. Subsequently, the Veteran underwent a VA examination. The RO/AMC readjudicated the claim in December 2011, determining that service connection was not warranted, and issued the Veteran a Supplemental Statement of the Case (SSOC). In April 2012, the Board requested a specialist medical opinion from the Veterans Health Administration (VHA). 38 C.F.R. § 20.901(a) (2011). The requested opinion was provided in July 2012 and associated with the Veteran's VA claims folder. The VHA opinion has also been provided to the Veteran and his representative, and he was afforded 60 days to provide additional argument or evidence. A response was received from the Veteran in September 2012. The appeal is now ready for disposition. Following the December 2011 SSOC, the Veteran submitted additional statements as well as an additional theory of entitlement, with a waiver of review by the Agency of Original Jurisdiction. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2011). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDING OF FACT A chronic low back disability was not documented in service or for many years later; and, the competent and credible evidence is against the finding that the Veteran's current low back disability is related to his active service, to include a slip and fall injury. CONCLUSION OF LAW The criteria for entitlement to service connection of a low back disorder, have not been met. 38 U.S.C.A. §§ 1131, 5103(a), 5103A (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309 (2011). REASONS AND BASES FOR FINDING AND CONCLUSION I. Duties to Notify and Assist Before addressing the merits of the issue, the Board notes that VA has a duty to notify and a duty to assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. §§ 3.159, 3.326(a). Proper notice from VA must inform the claimant and his representative, if any, prior to the initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ) of any information and any medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded must be included. Dingess v. Nicholson, 19 Vet. App. 473 (2006). Neither the Veteran nor his representative has alleged prejudice with respect to notice, as is required. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009); Goodwin v. Peake, 22 Vet. App. 128 (2008); Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). None is found by the Board. Indeed, VA's duty to notify has been more than satisfied. The Veteran was notified via letter dated in August 2006 of the criteria for establishing service connection, the evidence required in this regard, and his and VA's respective duties for obtaining evidence. The letter also notified him of how VA determines disability ratings and effective dates if service connection is awarded. The letters accordingly addressed all notice elements and predated the initial adjudication by the AOJ/RO in November 2006. Nothing more was required. Next, VA has a duty to assist a Veteran in the development of the claim. This duty includes assisting him in the procurement of service treatment records and other pertinent records, and providing an examination when necessary. See 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2011). The Veteran's service treatment records were lost in the St. Louis fire of 1973. As the service treatment records are unavailable, VA has a heightened duty to assist the Veteran. As such, the Board has considered the Veteran's statements regarding an in-service injury, as well as the lay statements of his mother and friend in service and their observations of the Veteran's condition and/or service circumstances at the time. Further, in compliance with its duty to assist, the RO/AMC associated the Veteran's service records regarding medical discharge due to a disability not currently on appeal, VA hospitalization records dated in the 1950's, VA outpatient treatment records, and Social Security Administration (SSA) records with the claims file. Private treatment records have also been associated by VA. Neither the Veteran nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Additionally, the Veteran was afforded a VA examination in December 2010. An addendum opinion was obtained in August 2011. Further, a VHA medical opinion was obtained in July 2012. The Board finds that the December 2010 examination was adequate with regard to the finding of a current diagnosis of degenerative disc disease as the examiner conducted a thorough interview with the Veteran regarding his symptoms as well as the appropriate tests. The Board acknowledges that the Veteran's claims file was not present at the December 2010 VA examination and that the examiner was unable to render a nexus opinion at that time because the records were unavailable. However, the same examiner reviewed the claims file and medical records when she rendered the August 2011 addendum opinion. The Board acknowledges that although the VA examiner provided some rationale for her negative nexus opinion, the basis for her opinion was not entirely clear. Additionally, the August 2011 opinion was rendered prior to receipt of the January 2012 private opinion in support of the Veteran's claim. Notwithstanding these deficiencies, the August 2011 addendum opinion was corrected by the July 2012 VHA opinion. The July 2012 VHA physician considered the claims file, as well as all of the Veteran's theories of entitlement and associated statements. The opinion contained a full discussion of the evidence of record, the Veteran's history of treatment, and the January 2012 positive nexus opinion by a private physician. Detailed rationale accompanied the negative opinion. Thus, the Board finds the July 2012 VHA opinion was adequate. Additionally, in May 2010, the Veteran was provided an opportunity to set forth his contentions during a hearing before a Decision Review Officer. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the U.S. Court of Appeals for Veterans Claims recently held that 38 C.F.R. § 3.103(c)(2) requires that the RO Decision Review Officer who chairs a hearing to fulfill two duties: (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010). Here, during the May 2010 hearing, the DRO identified the issue on appeal. Also, information was solicited regarding the onset of his low back disorder and whether there were any outstanding medical records. Therefore, not only was the issue "explained . . . in terms of the scope of the claim for benefits," but "the outstanding issues material to substantiating the claim" were also fully explained. See Bryant, 23 Vet. App. at 497. Moreover, the hearing discussion did not reveal any evidence that might be available that had not been submitted. Under these circumstances, nothing gave rise to the possibility that evidence had been overlooked with regard to the appellant's claims for service connection for a low back disorder. As such, the Board finds that, consistent with Bryant, the DRO complied with the duties set forth in 38 C.F.R. 3.103(c)(2) and that the Board may proceed to adjudicate the claims based on the current record. After a careful review of the file, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). Based on the foregoing, the Board finds that no additional assistance is required to fulfill VA's duty to assist. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001). II. Service Connection Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1131 (West 2002). If a chronic disease is shown in service, subsequent manifestations of the same chronic disease at any later date, however remote, may be service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b) (2011). However, continuity of symptoms is required where a condition in service is noted but is not, in fact, chronic or where a diagnosis of chronicity may be legitimately questioned. 38 C.F.R. § 3.303(b) (2011). Generally, service connection requires competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Hickson v. West, 12 Vet. App. 247 (1999). Further, service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 U.S.C.A. § 1113(b) (West 2002); 38 C.F.R. § 3.303(d) (2011). In the alternative, pursuant to 38 C.F.R. § 3.303(b) (2011), entitlement to service connection may be established by two other means-chronicity and continuity of symptomatology. Chronicity is established if the appellant can demonstrate (1) the existence of a chronic disease in service and (2) present manifestations of the same disease. Groves v. Peake, 524 F.3d 1306, 1309 (Fed. Cir. 2008). Continuity of symptomatology may be established if the appellant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post service symptomatology. Kent v. Nicholson, 20 Vet. App. 1, 13-14 (2006) (citing Savage v. Gober, 10 Vet. App. 488, 495 (1997), see also 38 C.F.R. § 3.303(b). In addition to the regulations cited above, service connection for certain diseases, such as arthritis, may also be established on a presumptive basis by showing that it manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 C.F.R. §§ 3.307(a)(3), 3.309(a) (2011). In addition to the regulations cited above, where a veteran served during a period of war or during peacetime service after December 31, 1946, he or she is presumed in sound condition except for defects noted when examined and accepted for service. 38 U.S.C.A. §§ 1111, 1137 (West 2002). A veteran who, during peacetime, served for at least six months or after December 31, 1946 is presumed to have been in sound condition when examined, accepted and enrolled in service, except for defects noted at the time of entrance, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C.A. §§ 1111, 1132, 1137 (West 2002); 38 C.F.R. § 3.304(b); see also Wagner v. Principi, 370 F. 3d 1089 (Fed. Cir. 2004) (holding that VA, rather than the claimant, bears the burden of proving that a disability preexisted service and was not aggravated therein). According to 38 C.F.R. § 3.304(b), the term "noted" denotes only such conditions that are recorded in examination reports. A history of pre-service existence of conditions recorded at the time of examination does not constitute a notation of such conditions but will be considered together with all other material evidence in determinations as to inception. 38 C.F.R. § 3.304(b)(1); Crowe v. Brown, 7 Vet. App. 238 (1994). The Board must determine whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either case, or whether the preponderance of the evidence is against the claim, in which case, service connection must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Veteran claims service connection under two theories of entitlement. He asserts that his current low back disorder is directly related to a slip and fall injury in service. Alternatively, he maintains that if he had a preexisting back disorder caused by rickets and/or scoliosis, that the disorder was aggravated by service, including the slip and fall in service. In assessing whether the Veteran was in sound condition upon entry into service, the Board notes that service treatment records, including any entrance examination, were lost in the St. Louis fire in 1973. Further, service records related to a medical discharge for a separate foot disability indicated that the foot disability preexisted service but the record was silent with regard to any low back disability. Therefore, giving the Veteran the benefit of the doubt, the Board finds that nothing was noted on entrance. Clear and unmistakable evidence is thereby required to rebut the presumption of soundness. Post-service treatment records dated shortly following service reveal the possibility of a preexisting low back disorder. An April 1955 VA hospitalization record for a disability not on appeal, indicated a secondary diagnosis of other conditions including "idiopathic scoliosis, residuals of childhood rickets." However, following review of the treatment record, the July 2012 VHA opinion noted that the treatment record did not provide clear and unmistakable evidence of a preexisting disability. The VHA examiner indicated that it was unclear how the diagnosis was reached as current X-ray studies do not support the diagnoses. X-rays dated in 2010 did not document lumbar scoliosis. The VHA physician opined that scoliosis could not have resolved spontaneously. Further, the examiner opined that the diagnosis of "idiopathic scoliosis, residuals of childhood rickets" makes no sense medically. The VHA physician noted that if there was scoliosis and it was attributed to rickets, it would not be idiopathic. As no pre-service treatment records are available and the only evidence of a preexisting scoliosis disability is the post-service 1958 hospital record concerning a separate issue with a secondary diagnosis that is found to not make any medical sense, the Board will not afford the 1958 treatment record any weight. The Board will proceed under the premise that his low back disorder did not preexist service. The presumption of soundness applies and has not been rebutted. Regarding direct service connection, the Board has considered the Veteran's statements that he sustained a slip and fall injury in service, on or about New Year's Eve 1954. The Board finds the Veteran is competent to report that he fell in service and that his back hurt following the fall, as these observations came to him through his sense. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). The Board has considered the Veteran's mother's statement regarding her observation of his pain when he came home after the fall. His mother is competent to report observations of him wincing or engaging in other types of demonstration that his back hurts. She is also competent to report that she has heard him complain of back pain. The Board has also considered the Veteran's friend's letter regarding the icy conditions during the period in which the Veteran claims to have fallen and finds the statement to be competent. The Board finds all of the statements to be credible. As noted above, the Veteran's service treatment records are not available for review and VA has a heightened duty to assist. Giving the Veteran the benefit of the doubt, the Board finds sufficient evidence that a slip and fall accident occurred during service, which resulted in a back injury. Shedden element (2) has been met. Post-service treatment records and statements indicate that the Veteran was diagnosed with a disc herniation in 1983. The Veteran has also consistently reported that he underwent three surgeries on his back since 1983. VA outpatient treatment records have listed a diagnosis of degenerative disc disease on the Veteran's problem list since at least February 2006. The diagnosis of degenerative disc disease was confirmed by X-ray at the December 2010 VA examination. Thus, Shedden element (1) has been met. As noted above, under 38 C.F.R. § 3.307, service connection may be presumed for certain conditions, including degenerative disc disease, if the disorder was disabling to a degree of 10 percent or more within one year following service. In this case, however, degenerative disc disease was not diagnosed until nearly 50 years following service separation. Even the Veteran's own statements regarding the disc herniation indicate that disc herniation did not occur until nearly 30 years following service separation. As the Veteran's degenerative disc disease was not diagnosed within one year of service, service connection is not warranted on a presumptive basis. 38 C.F.R. § 3.307. The Board has considered the Veteran's statements of continuity of symptomatology since service as well as those of his daughter, who says she has noticed her father's complaints of back pain for her entire life (she was born in 1965). Consideration is also given to statements from V.C. and L.D. who have reported that the Veteran has had back problems since service. M.H. and R.R. similarly report that the Veteran has had back problems for as long as they have known him (time frame not specified). Statements from B.S. and W.W. indicate that that the Veteran appeared to be in good health prior to service. J.H. reported in 2006 that he had seen the Veteran struggle with back problems for 25 years. A similar statement was received from P.D., who reported the Veteran had back problems since the 1980s. The Board has also considered statements from W.M., W.B., G.H., D.H., R.B., F.C., B.R., and L.R. who all reported that they knew the Veteran prior to service and that he had no problems prior to service but had back problems since service. The Board appreciates that the Veteran has submitted numerous signatures in support of a finding that his statements should be considered credible. The Board must analyze the credibility and probative value of the evidence, account for the evidence that it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir.1996) (table); Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). Lay testimony is competent to establish the presence of observable symptomatology and may provide sufficient support for a claim of service connection. Barr v. Nicholson, 21 Vet.App. 303, 307 (2007). The Board acknowledges that lay evidence concerning continuity of symptoms after service, if credible, is ultimately competent. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). In this case, the Veteran is competent to report symptoms of back pain because this requires only personal knowledge as it comes to him through his senses. Layno v. Brown, 6 Vet. App. 465, 469 (1994). Similarly, his daughter and friends are competent to report observations of him wincing or engaging in other types of demonstration that his back hurts. They are also competent to report that they have heard him complain of back pain. The Board finds that the various reports of continued symptomatology since active service, while competent, is nonetheless not credible. It is true that that the Veteran sought service connection for a low back disorder four years after service, in 1958, and complained of back pain at that time. However, when he was examined in May 1958, he related that he fully recovered from his in-service injury. He was also shown to have an essentially negative physical examination of the spine. No disability of the spine was indentified other than poor posture. Importantly, the Veteran was no seen again until April 1969 (11 years later), when he complained that he injured his back on the job. There was no reference to service or chronic low back pain at that time. If he had been experiencing chronic back problems since service, as he and his family and friends attest, then one would expect that such a history would be reported. Curry v. Brown, 7 Vet. App. 59, 68 (1994) (contemporaneous evidence has greater probative value than history as reported by the claimant); Buczynski v. Shinseki, 24 Vet. App. 221, 224 (2011) (where there is a lack of notation of medical condition or symptoms where such notation would normally be expected, the Board may consider this as evidence that the condition or symptoms did not exist). Following the April 1969 complaints, the Veteran was not treated again for back pain until September 1980, after he injured his back lifting furniture. The injury was described as "acute" and again there were no findings related to the service injury or a history of back pain. This is another example of where providing a 20 year history of back problems, if such existed, would be expected. Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive proper care). Next, the Veteran sustained a motor vehicle accident in September 1983, in which he was rear ended while sitting in his truck. He testified before the DRO that he later had to have a disc removed. Treatment records also show that he underwent a hemilaminectomy of L4-L5 in August 1984. During a December 2002 VA outpatient psychiatric visit, he mentioned that he had been rear-ended in his semi-truck while stopped at a road block in 1993. Another VA treatment record indicates that he had another trucking accident in 1998. See October 2002 VA outpatient treatment record. Notably, he did not report his in-service slip and fall or continuous back pain since service, when he was treated for the post-service incidents of back pain. It was not until he filed his claim that the Veteran provided a history of back pain since service. Given the lack of documented complaints of the service injury during post-service treatment visits and long gaps of time without documented treatment for low back pain, the Board finds the Veteran's statements asserting continuity of symptomatology since service lack credibility and are without probative value. See, e.g. Madden v. Gober, 125 F.3d 1477, 1481 (1997) (the Board is entitled to discount the credibility of evidence in light of its own inherent characteristics and its relationship to other items of evidence). Next, service connection may be granted when the evidence establishes a nexus between active duty service and current complaints. In this case, the Board finds that the weight of the competent evidence does not attribute the Veteran's low back disability to active duty. To that end, the Board has considered the December 2010 VA examination and opinion, the August 2011 VA addendum opinion, January 2012 private opinion, and the July 2012 VHA opinion undertaken to specifically address the Veteran's low back disorder claim. Upon physical examination and review of X-rays, the December 2010 VA examiner diagnosed degenerative disc disease of the lumbar spine. Subsequently, in August 2011, the same VA examiner submitted an addendum opinion following review of the claims file and two available service treatment records. The examiner determined that it was less likely as not that the Veteran's degenerative disc disease was caused by service. The examiner noted that the Veteran's 1983 surgery for a herniated disc took place following a motor vehicle accident. The examiner also emphasized that the Veteran's back treatment began 29 years after service and after working during those post-service years as a truck driver. The Board finds that it would not be unreasonable to infer that the examiner's emphasis on intervening events since service was that those events rather than the slip and fall in service, led to the Veteran's current diagnosis. The July 2012 VHA physician also opined that it was less likely than not that the Veteran's current disorder is related to service for several reasons. First, regarding the Veteran's contention that his 1983 disc herniation surgery was due to his slip and fall in service, the VHA physician indicated that a slip and fall, unlike a fall from a height, would be unlikely to cause a disc injury. But, the July 2012 VHA physician noted that it was well-recognized that a rear end motor vehicle accident can cause acute disc herniation. And, the Veteran here was involved in a rear end motor vehicle accident in 1983 which resulted in an acute disc herniation and required surgical intervention. The Veteran required two additional surgeries to address the 1983 injury, disc condition, and progression of the degenerative spinal condition related to the disc herniation of 1983. The VHA physician also noted that it was conceivable that a slip and fall injury could cause a compression fracture but that in this case, there was no evidence of a compression fracture on the 2010 X-ray. The VHA physician emphasized that it was well recognized that heavy manual labor, such as work as a farmer, predisposes people to disc pathology due to repeated lifting, bending, and straining. Similarly, the VHA physician noted that it was well recognized that employment as a truck driver causes statistically significant increase in the prevalence of disc disease due to factors including prolonged sitting, lifting requirements, and vibration. Here, the Veteran has reported that he has spent many years working as both a truck driver and on a farm. See buddy letters from W.M., W.B., and G.H. The VHA physician also noted that the three back surgeries may also have led to the current complaints because it is not uncommon for individuals who undergo back surgery to have residual symptoms. In sum, the VHA physician opined that the most likely scenario was that the Veteran's current disability is caused by a degenerative condition of the lumbar spine directly related to the disc herniation of 1983. Based on all of the foregoing, the VHA physician determined that it was less likely than not that the Veteran's current disorder was related to the fall in service. The Board places a high probative value on the July 2012 VHA opinion. The Board acknowledges that a private medical opinion from Dr. S., dated in January 2012, offered a positive opinion regarding a relationship between the Veteran's current disorder and service. Dr. S. submitted a letter stating that he had seen the Veteran and that it was his opinion that it is possible and very likely that the Veteran's current disability was caused by his previous trauma and injury in 1954, which is documented in his old records. Dr. S. also explained that he was unable to objectively verify the opinion as he has not been the Veteran's primary care provider since that time. Notably, Dr. S. did not offer any rationale for his opinion that the Veteran's current disorder was related to service. He also failed to discuss the Veteran's extensive history of post-service back injuries as well as the absence of documented back disability until many years post-service. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (noting that a central issue in the persuasiveness of a medical opinion is whether the examiner was informed of the relevant facts in rendering a medical opinion). Moreover, the complete lack of rationale to support Dr. S.'s opinion juxtaposed with the very detailed opinion of the July 2012 VHA physician regarding the lack of a relationship between the current disability and service injury, as well as recognized intervening back injuries. The detailed discussion of the Veteran's documented medical history as well as his lay statements makes this opinion highly probative. Stefl v. Nicholson, 21 Vet. App. 120, 123-24 (2007) (holding that a medical opinion must be supported by an analysis that the Board can consider and weigh against contrary opinions and should address the appropriate theories of entitlement). In so finding, the preponderance of the evidence is against the claim for service connection. The Board has considered the Veteran's statement that a relationship asserting a nexus between his currently-diagnosed degenerative disc disease, and active duty service. Although the Veteran is competent to report his back pain, he is not competent to render a medical opinion as to the etiology of this disability. In this regard, the Board acknowledges lay evidence may be competent to establish medical etiology or nexus. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). Here, while the Veteran is competent to describe his low back pain and experiences in service, the Board accords his statements regarding the etiology of his current low back pain little probative value as he is not competent to opine on such a complex medical question. Specifically, where the determinative issue is one of medical causation, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue. See Jones v. West, 12 Vet. App. 460, 465 (1999). Additionally, the Veteran has offered only conclusory statements regarding the etiology of his current disorder. In contrast, the July 2012 VHA physician reviewed his records including X-ray findings, considered his reported history, as well as the positive opinion that is of record. Therefore, the Board finds that the July 2012 VHA opinion is the most probative evidence of record. As such, the preponderance of the evidence weighs against a finding that the Veteran's degenerative disc disease is due to any event or injury in service. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107 (West 2002); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). However, as reflected by the above discussion, the preponderance of the evidence is against the Veteran's claim for service connection. Therefore, his claim must be denied. ORDER Service connection for a low back disorder is denied. ____________________________________________ MICHAEL A. HERMAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs